DASC-LOT Framework and S3 Metric: A Novel Evaluation and Benchmarking Method to Assess Initiation, Duration, and Spectrum of Antimicrobial Usage at Inpatient Hospital Settings

Michihiko Goto; Shungo Imai; Hyunkeun Cho; James A Merchant; Matthew Bidwell Goetz; Eli N Perencevich; Bruce Alexander; Qianyi Shi; Andrea Holcombe; Daniel J Livorsi

doi:10.1093/cid/ciag389

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DASC-LOT Framework and S3 Metric: A Novel Evaluation and Benchmarking Method to Assess Initiation, Duration, and Spectrum of Antimicrobial Usage at Inpatient Hospital Settings

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DASC-LOT Framework and S3 Metric: A Novel Evaluation and Benchmarking Method to Assess Initiation, Duration, and Spectrum of Antimicrobial Usage at Inpatient Hospital Settings

Michihiko Goto, Shungo Imai, Hyunkeun Cho, James A Merchant, Matthew Bidwell Goetz, Eli N Perencevich, Bruce Alexander, Qianyi Shi, Andrea Holcombe and Daniel J Livorsi

Clinical infectious diseases

06/25/2026

DOI: 10.1093/cid/ciag389

PMID: 42345285

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Abstract

Inpatient antimicrobial stewardship programs (ASPs) promote avoiding unnecessary initiation, excessively long duration, and overly broad-spectrum selection of antimicrobials, but currently available metrics do not adequately reflect or distinguish these three components. We aimed to develop a novel framework that captures them while providing information specific to each, based on Days of Antimicrobial Spectrum Coverage (DASC) and length of therapy (LOT). We developed a three-level conditional modeling framework to extract hospital-level variability, risk-adjusted for three components (initiation, duration, and spectrum). This was applied to data from 118 Veterans Health Administration (VHA) hospitals, with models built on 2022-2023 data and validated with 2024 data. Patient demographics, intensive care status, admitting specialty, 86 comorbidities, and 224 procedure categories were considered candidate variables for risk adjustment. Overall hospital performance was evaluated using a composite metric that integrated three components ("S3 [start, stop, select] Metric") and was visualized in a radar chart for each hospital. The cohort included 727,958 unique patients with 9,363,922 days present. Hospital-level usage ranged widely (DASC per 1,000 DP: 1,311-5,275 [interquartile range (IQR): 2,738-3,563]; LOT per 1,000 DP: 132.2-517.6 [IQR: 301.0-367.5]). Risk-adjustment models included 116 variables for initiation, 77 for duration, and 91 for spectrum components. S3 metrics ranged from 0.703 to 1.572 (IQR: 0.906-1.086). A three-component evaluation could provide specific information on each hospital's usage patterns. We propose a DASC-LOT framework and S3 metric to assess ASP practices in initiation, duration, and spectrum separately while providing overall composite benchmarking.

Benchmarking

Inpatient Antimicrobial Use

Risk-Adjustment

Antimicrobial Stewardship

Mathematical Framework

Quality Metrics

UIOWA OA Agreement

Details

Title: Subtitle: DASC-LOT Framework and S3 Metric: A Novel Evaluation and Benchmarking Method to Assess Initiation, Duration, and Spectrum of Antimicrobial Usage at Inpatient Hospital Settings
Creators: Michihiko Goto - University of Iowa
Shungo Imai - University of Iowa
Hyunkeun Cho - Human Longevity (United States)
James A Merchant - Iowa City VA Health Care System
Matthew Bidwell Goetz - University of California, Los Angeles
Eli N Perencevich - University of Iowa
Bruce Alexander - Iowa City VA Health Care System
Qianyi Shi - University of Iowa
Andrea Holcombe - University of Iowa
Daniel J Livorsi - University of Iowa
Resource Type: Journal article
Publication Details: Clinical infectious diseases
DOI: 10.1093/cid/ciag389
PMID: 42345285
NLM abbreviation: Clin Infect Dis
ISSN: 1537-6591
eISSN: 1537-6591
Publisher: Oxford University Press
Language: English
Electronic publication date: 06/25/2026
Academic Unit: Neurology; Pharmacy; Psychiatry; Infectious Diseases; Epidemiology; General Internal Medicine; Internal Medicine
Record Identifier: 9985176657402771

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